20-495 View Medical Necessity Guidelines for Paclitaxel Online in Four Steps or Less
Date: 08/03/20
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
Refer to the payment integrity policy for details
Health Net* has implemented a payment integrity policy that describes medical necessity guidelines for paclitaxel (Abraxane®). Refer to the table on the next page for a description of the policy.
Health Net’s reimbursement to contracted providers for covered services is based on specific negotiated contract provisions supplemented by the contents of disclosed and consistent fee schedules, payment policies and coding methodologies.
Access new policies simply
The options below show how to view polices either via the provider website or by going directly to the Provider Library.
Option 1: Go to the provider website at:
- provider.healthnet.com and select Working with Health Net > Contractual > Policy Library > Go to the Provider Library.
- Once in the Provider Library, select Cal MediConnect, then go to Provider Manual > Claims Coding Policies and select Clinical Payment Policies or Payment Integrity Policies for the respective policy.
Option 2: Go directly to the Provider Library at:
- providerlibrary.healthnetcalifornia.com.
- Once in the Provider Library, select a line of business, then go to Provider Manual > Claims Coding Policies and select Clinical Payment Policies or Payment Integrity Policies for the respective policy.
Policy chart
The following table lists the policy number and name, a description of the policy and applicable providers.
Policy number and name | Description of policy | Providers |
CP.PHAR.176, Paclitaxel, protein-bound (Abraxane) | This policy advises that Abraxane is medically necessary when the criteria described in the policy are met. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. Payment for claims submitted outside of these medically necessary guidelines will be denied. Please see the CPT and ICD-10 coding guidelines documented in the policy. The applicable claims edit will be applied to claims for dates of service after February 14, 2020. | Physicians, participating physician groups, hospitals and ancillary providers |
Additional information
Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library, located on Health Net’s provider website at provider.healthnet.com.
Providers are encouraged to access Health Net’s provider portal online at provider.healthnet.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries and more.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by county within 60 days at:
Line of Business | Telephone Number | Email Address |
Cal MediConnect – Los Angeles County | 1-855-464-3571 | |
Cal MediConnect – San Diego County | 1-855-464-3572 |